<div class="panel panel-primary">
	<div class="panel-heading">
		<h3>Learn How We Can Help You!</h3>
	</div>
	<div class="panel-body">
		
		
		<p>Fill out this simple form with a brief description of your situation and one of our representatives will contact you as soon as possible to schedule your free initial consultation!<p>
		
		<p><em>(We will NEVER send you SPAM or sell your email)</em></p>
		
		<form class="contact-sidebar" role="form" action="" method="post">
			<div class="form-group">
				<label for="name">What is your name?</label>
				<input type="text" class="form-control" name="name" id="name" placeholder="What is your name?" required>
			</div>

			<div class="form-group">
				<label for="email">What is your email address?</label>
				<input type="email" class="form-control" name="email" id="email" placeholder="What is your email address?" required>
			</div>

			<div class="form-group">
				<label for="phone">What is your phone number?</label>
				<input type="text" class="form-control" name="phone" id="phone" placeholder="What is your phone number?" required>
			</div>
			
			<div class="form-group calltimes">
				<label for="call_from" style="display: block !important">Which times are best to call? (click to change)</label>
				Between <input type="text" class="call-from form-control" name="call_from" id="call_from" required>
				and	<input type="text" class="call-until form-control" name="call_until" id="call_until" required>
				<script>
					$(document).ready(function(){
						$('input.call-from').timepicker({
							defaultTime: new Date(0,0,0,8,0,0),
						});
						$('input.call-until').timepicker({
							defaultTime: new Date(0,0,0,18,0,0),
						});
					});
				</script>
			</div>
			
			
			<div class="form-group">
				<select name="state" id="state" class="form-control placeholder" required>
					<option selected disabled value="">In which state do you live?</option>
					<option value="AL">Alabama</option>
					<option value="AK">Alaska</option>
					<option value="AZ">Arizona</option>
					<option value="AR">Arkansas</option>
					<option value="CA">California</option>
					<option value="CO">Colorado</option>
					<option value="CT">Connecticut</option>
					<option value="DE">Delaware</option>
					<option value="DC">District Of Columbia</option>
					<option value="FL">Florida</option>
					<option value="GA">Georgia</option>
					<option value="HI">Hawaii</option>
					<option value="ID">Idaho</option>
					<option value="IL">Illinois</option>
					<option value="IN">Indiana</option>
					<option value="IA">Iowa</option>
					<option value="KS">Kansas</option>
					<option value="KY">Kentucky</option>
					<option value="LA">Louisiana</option>
					<option value="ME">Maine</option>
					<option value="MD">Maryland</option>
					<option value="MA">Massachusetts</option>
					<option value="MI">Michigan</option>
					<option value="MN">Minnesota</option>
					<option value="MS">Mississippi</option>
					<option value="MO">Missouri</option>
					<option value="MT">Montana</option>
					<option value="NE">Nebraska</option>
					<option value="NV">Nevada</option>
					<option value="NH">New Hampshire</option>
					<option value="NJ">New Jersey</option>
					<option value="NM">New Mexico</option>
					<option value="NY">New York</option>
					<option value="NC">North Carolina</option>
					<option value="ND">North Dakota</option>
					<option value="OH">Ohio</option>
					<option value="OK">Oklahoma</option>
					<option value="OR">Oregon</option>
					<option value="PA">Pennsylvania</option>
					<option value="RI">Rhode Island</option>
					<option value="SC">South Carolina</option>
					<option value="SD">South Dakota</option>
					<option value="TN">Tennessee</option>
					<option value="TX">Texas</option>
					<option value="UT">Utah</option>
					<option value="VT">Vermont</option>
					<option value="VA">Virginia</option>
					<option value="WA">Washington</option>
					<option value="WV">West Virginia</option>
					<option value="WI">Wisconsin</option>
					<option value="WY">Wyoming</option>
				</select>
			</div>
			
			<div class="form-group">
				<select name="loss_type" id="loss_type" class="form-control placeholder" required>
					<option selected disabled value="">What type of damage occurred?</option>
					<option value="Fire">Fire or Smoke Damage</option>
					<option value="Water">Flood or Water Damage</option>
					<option value="Hurricane">Hurricane Damage</option>
					<option value="Tornado">Tornado Damage</option>
					<option value="Other">Other (Please Specify Below)</option>
				</select>
			</div>
			
			<div class="form-group">
				<label for="message">Please describe your situation...</label>
				<textarea name="message" id="message" class="form-control" placeholder="Please describe your situation..." rows="5" required></textarea>
			</div>
			
			<div class="form-group">
				<p><input type="checkbox" name="is_dwelling" id="is_dwelling">
				<label style="font-weight: normal; display: inline !important;" for="is_dwelling">I'd like to speak to someone regarding a <strong>dwelling claims</strong> consultation.</label>
			</div>
			
			<div class="form-group">
				<p><input type="checkbox" required name="terms" id="terms">
				<label style="font-weight: normal; display: inline !important;" for="terms">I understand and accept <a id="terms-link" href="javascript:void(0);">these terms of use</a>.</label>
				
				<div id="terms-dialog">
					<h3>Your Privacy</h3>
					<h4>Acceptance of Terms</h4>
<p>This website is operated by Claim Everything. It is intended for your personal information,
education and communication. Please feel free to browse the Site; however, your access 
and use of this Site and any provided services resulting from use of this website is subject 
to these Terms of Use and all applicable laws. By accessing and browsing this website, you 
accept, without limitation or qualification, these Terms of Use. Claim Everything reserves 
the right to limit or terminate your access to this website.</p>
					
					<h4>Limited Right to Use and Copyrights</h4>
<p>The information and materials on this website and provided as part of services resulting 
from this website, are protected by copyrights, trademarks and/or other proprietary rights 
and laws. The viewing, printing or downloading of any materials, content or information 
from this website or resulting from services obtained through this website grants you only a 
limited, non-exclusive license for use solely by you for your own personal use and not for 
republication, distribution, sale, publication, preparation of derivative works or other use. No 
part of any content, materials or information may be reproduced in any form or 
incorporated into any information retrieval system, electronic or mechanical, other than for 
your personal use, except as expressly authorized by Claim Everything and is otherwise 
strictly prohibited.</p>
					
					<h4>General Disclaimer</h4>
<p>This website and related services resulting from use of this website, is an informational and
educational resource to assist you with your insurance claim. While Claim Everything hopes 
to provide you with useful information and assistance, we do not provide legal advice; or 
specific advice regarding which service providers you should use.  Legal and insurance 
principles discussed at this website or through services resulting from use of this website, 
may differ substantially in individual situations or in different states. When dealing with any 
legal matter you should not rely on the materials or the content provided on this website or 
information provided by related services from this website without first seeking the advice 
of an attorney about your particular situation and facts.  Nothing contained on this website 
should be construed to constitute a recommendation or endorsement of any service, 
website, insurance professional, law firm or attorney. Any listing, name, content, material of 
any insurance professional, attorney or law firm found on this website or suggested through 
the website services does not constitute an endorsement, recommendation or referral of 
such persons. When deciding to hire any insurance professional, attorney or law firm you 
should do your own research and not solely rely on the materials found on this website or 
provided through services on this website. Any information or product development 
resulting from this website or use of services  from this website are not intended to replace 
legal or licensed professional advice in your state of residence.</p>

<p><strong>1. Limitation of Liability:</strong> Under no circumstances will Claim Everything or any of its officers, 
employees, directors, agents or affiliates be liable for any direct, indirect, punitive, 
incidental, special, or consequential damages that result from the use of, or the inability to 
use, this website or any of this websites services.</p>

<p>We reserve the right to cancel, suspend or deny a free consultation for any reason.  By 
using this website, you agree you cannot hold Claim Everything or any of its officers 
employees, directors, agents or affiliates liable for any direct, indirect, punitive, incidental, 
special, or consequential damages that results from a free consultation being cancelled, 
suspended or denied.</p>

<p>We reserve the right to cancel, suspend or deny contracted or other services for any reason.  
By using this website, you agree you cannot hold Claim Everything or any of its officer’s 
employees, directors, agents or affiliates liable for any direct, indirect, punitive, incidental, 
special, or consequential damages that results from early termination of contracted 
services.  Claim Everything will provide a full refund for services not yet rendered within 7 
business days of cancellation.  Fees for rendered services will not be refunded and/or will be 
payable within 7 days of cancellation.  If you cancel services, fees for services rendered will 
not be refunded  and/or will be payable within 7 business days and a refund of pre paid 
services will be issued  within 7 business days.</p>

<p>The use of any information provided on this website is solely at your own risk. Always seek 
the advice of an insurance professional, attorney, or other professional or licensed advisor 
as appropriate. Do not disregard insurance, legal, or other professional or licensed advice or 
delay in seeking it because of something you have read on this website.</p>

<p><strong>2. Indemnification.</strong> You will indemnify, defend, and hold harmless  Claim Everything and its 
officers, employees, directors, agents and affiliates from any and all claims, demands, 
damages, costs, and liabilities, including reasonable attorneys' fees and costs, resulting 
from or arising out of your acts or omissions in using this website, including your breach of 
these Terms of Use.</p>

<p><strong>3. Modifications to Term of Use.</strong> Claim Everything may change, modify, update, add to, or 
remove portions of these Terms of Use at any time. Please check these Terms of Use 
periodically for changes. Your continued use of the Site following the posting of any changes 
will signify your acceptance of those changes.</p>

<p><strong>4. Any action related to these Terms of Use</strong> or the use of the services provided by this 
website will be governed by the laws of the State of North Carolina, without regard to 
conflicts of laws principles. The state and federal courts located in Union County,
North Carolina shall have sole jurisdiction over any dispute arising hereunder, and by the 
use of this website and any of the services offered through this website you hereby consent 
to the personal jurisdiction of such courts for all such purposes.</p>

<p><strong>5. Privacy Policy.</strong> Claim Everything understands you may provide personal information and 
other data when you come to the website. While Claim Everything takes all reasonable steps 
to protect and safeguard your personal information and other data, we cannot guarantee 
that our system is failsafe or that information is not subject to the interception, alteration, 
and unauthorized access by third parties. Nor does Claim Everything guarantee absolute 
security and confidentiality. Furthermore, Claim Everything may disclose your personal 
information as required by law, rule, regulation or court order.</p>

<p><strong>6. By agreeing to these Terms of Use</strong> you are agreeing to Claim Everything’s Privacy Policy.     
By using our Website, you agree to the Terms of Use and the Privacy Policy.</p>


					
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				</div>
				
			</div>
			
			
			<input type="submit" name="submit" value="Send Message &raquo;" class="btn btn-warning pull-right">
		</form>
		
	</div>
</div>